Prolotherapy for knee osteoarthritis using hypertonic dextrose vs other interventional treatments: systematic review of clinical trials.

BACKGROUND: To evaluate the efficacy and safety of prolotherapy with hypertonic dextrose in patients with knee osteoarthritis. A systematic search was performed in electronic databases including PUBMED, SCIELO, DIALNET and Google Scholar. MAIN BODY: We searched for randomized clinical trials that evaluated therapeutic interventions in patients with knee osteoarthritis. These trials compared the effect of intra-articular and / or extra-articular infiltrations of hypertonic dextrose vs the effect of intra-articular and / or extra-articular infiltrations of other substances or some interventional procedure application, via assessing pain, physical function and secondary effects and / or adverse reactions. Ten randomized clinical trials were included in this systematic review, the total sample size comprised 328 patients treated with hypertonic dextrose (prolotherapy) vs 348 controls treated with other infiltrations such as local anesthetics, hyaluronic acid, ozone, platelet-rich plasma or interventional procedures like radiofrequency. CONCLUSIONS: In terms of pain reduction and function improvement, prolotherapy with hypertonic dextrose was more effective than infiltrations with local anesthetics, as effective as infiltrations with hyaluronic acid, ozone or radiofrequency and less effective than PRP and erythropoietin, with beneficial effect in the short, medium and long term. In addition, no side effects or serious adverse reactions were reported in patients treated with hypertonic dextrose. Although HDP seems to be a promising interventional treatment for knee OA, more studies with better methodological quality and low risk of bias are needed to confirm the efficacy and safety of this intervention.

Effects of hypertonic dextrose injection in chronic supraspinatus tendinopathy of the shoulder: a randomized placebo-controlled trial.

BACKGROUND: Rotator cuff lesions are common causes of shoulder pain. Although patients with symptoms caused by chronic rotator cuff tendinopathy can be treated using conservative treatments, some of them may still experience refractory symptoms. Hypertonic dextrose prolotherapy (DPT) may be another treatment choice for these refractory symptoms. AIM: The aim of this study was to evaluate the effects of an ultrasound-guided hypertonic dextrose injection for patients with chronic supraspinatus tendinopathy. DESIGN: Randomized double-blind placebo-controlled trial. SETTING: Academic medical center. POPULATION: Outpatients patients (N.=31) with chronic supraspinatus tendinopathy and shoulder pain for more than six months. METHODS: Study group treated with one dose of an ultrasound-guided hypertonic dextrose (20%) injection at the supraspinatus enthesis site, whereas control patients received one dose of 5% normal saline through the same method. The Visual Analog Scale (VAS), Shoulder Pain And Disability Index (SPADI), shoulder active range of motion (AROM) and ultrasonographic thickness and histogram results of the supraspinatus tendon were evaluated before intervention and at two and six weeks after intervention. The outcome differences between the study and control groups were analyzed by using repeated-measures analysis of variance (ANOVA). RESULTS: In total, 31 patients completed the study. The study group indicated a significant improvement in the VAS (P=0.001), SPADI scores (P=0.017), shoulder AROM of flexion (P=0.039), and abduction (P=0.043) compared with the control group at two weeks after the injection. However, the effect did not sustain until six weeks after the injection. No differences in the histograms and morphological changes (thickness) were noted before and after injection in both groups. CONCLUSIONS: This study revealed that the ultrasound-guided hypertonic dextrose injection relieved pain, disability, and improved shoulder AROM for a short period in patients with chronic supraspinatus tendinopathy. CLINICAL REHABILITATION IMPACT: For patients with chronic shoulder pain and supraspinatus tendinopathy, ultrasound-guided hypertonic dextrose injections can provide relief from pain, disability, and shoulder range of motion for up to two weeks after intervention.

Saline irrigation for chronic rhinosinusitis.

BACKGROUND: This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Nasal saline irrigation is commonly used to improve patient symptoms. OBJECTIVES: To evaluate the effects of saline irrigation in patients with chronic rhinosinusitis. SEARCH METHODS: The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 9); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 30 October 2015. SELECTION CRITERIA: Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing saline delivered to the nose by any means (douche, irrigation, drops, spray or nebuliser) with (a) placebo, (b) no treatment or (c) other pharmacological interventions. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation and discomfort. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS: We included two RCTs (116 adult participants). One compared large-volume (150 ml) hypertonic (2%) saline irrigation with usual treatment over a six-month period; the other compared 5 ml nebulised saline twice a day with intranasal corticosteroids, treating participants for three months and evaluating them on completion of treatment and three months later. Large-volume, hypertonic nasal saline versus usual care One trial included 76 adult participants (52 intervention, 24 control) with or without polyps.Disease-specific HRQL was reported using the Rhinosinusitis Disability Index (RSDI; 0 to 100, 100 = best quality of life). At the end of three months of treatment, patients in the saline group were better than those in the placebo group (mean difference (MD) 6.3 points, 95% confidence interval (CI) 0.89 to 11.71) and at six months there was a greater effect (MD 13.5 points, 95% CI 9.63 to 17.37). We assessed the evidence to be of low quality for the three months follow-up and very low quality for the six months follow-up. Patient-reported disease severity was evaluated using a "single-item sinus symptom severity assessment" but the range of scores is not stated, making it impossible for us to determine the meaning of the data presented.No adverse effects data were collected in the control group but 23% of participants in the saline group experienced side effects including epistaxis. General HRQL was measured using SF-12 (0 to 100, 100 = best quality of life). No difference was found after three months of treatment (low quality evidence) but at six months there was a small difference favouring the saline group, which may not be of clinical significance and has high uncertainty (MD 10.5 points, 95% CI 0.66 to 20.34) (very low quality evidence). Low-volume, nebulised saline versus intranasal corticosteroids One trial included 40 adult participants with polyps. Our primary outcome of disease-specific HRQL was not reported. At the end of treatment (three months) the patients who had intranasal corticosteroids had less severe symptoms (MD -13.50, 95% CI -14.44 to -12.56); this corresponds to a large effect size. We assessed the evidence to be of very low quality. AUTHORS' CONCLUSIONS: The two studies were very different in terms of included populations, interventions and comparisons and so it is therefore difficult to draw conclusions for practice. The evidence suggests that there is no benefit of a low-volume (5 ml) nebulised saline spray over intranasal steroids. There is some benefit of daily, large-volume (150 ml) saline irrigation with a hypertonic solution when compared with placebo, but the quality of the evidence is low for three months and very low for six months of treatment.

Mannitol versus hypertonic saline for brain relaxation in patients undergoing craniotomy

BACKGROUND: Patients with brain tumour usually suffer from increased pressure in the skull due to swelling of brain tissue. A swollen brain renders surgical removal of the brain tumour difficult. To ease surgical tumour removal, measures are taken to reduce brain swelling, often referred to as brain relaxation. Brain relaxation can be achieved with intravenous fluids such as mannitol or hypertonic saline. This review was conducted to find out which of the two fluids may have a greater impact on brain relaxation. OBJECTIVES: To compare the effects of mannitol versus those of hypertonic saline on intraoperative brain relaxation in patients undergoing craniotomy. METHODS: Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 10), Medline via Ovid SP (1966 to October 2013) and Embase via Ovid SP (1980 to October 2013). We also searched specific websites, such as www.indmed.nic.in, www.cochrane-sadcct.org and www.Clinicaltrials.gov. Selection criteria: We included randomized controlled trials (RCTs) that compared the use of hypertonic saline versus mannitol for brain relaxation. We also included studies in which any other method used for intraoperative brain relaxation was compared with mannitol or hypertonic saline. Primary outcomes were longest follow-up mortality, Glasgow Outcome Scale score at three months and any adverse events related to mannitol or hypertonic saline. Secondary outcomes were intraoperative brain relaxation, intensive care unit (ICU) stay, hospital stay and quality of life. Data collection and analysis: We used standardized methods for conducting a systematic review, as described by the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. All analyses were made on an intention-to-treat basis. We used a fixed-effect ...

Effects of hypertonic buffer composition on lymph node uptake and bioavailability of rituximab, after subcutaneous administration.

The subcutaneous administration of biologics is highly desirable; however, incomplete bioavailability after s.c. administration remains a major challenge. In this work we investigated the effects of excipient dependent hyperosmolarity on lymphatic uptake and plasma exposure of rituximab as a model protein. Using Swiss Webster (SW) mice as the animal model, we compared the effects of NaCl, mannitol and O-phospho-L-serine (OPLS) on the plasma concentration of rituximab over 5 days after s.c. administration. An increase was observed in plasma concentrations in animals administered rituximab in hypertonic buffer solutions, compared with isotonic buffer. Bioavailability, as estimated by our pharmacokinetic model, increased from 29% in isotonic buffer to 54% in hypertonic buffer containing NaCl, to almost complete bioavailability in hypertonic buffers containing high dose OPLS or mannitol. This improvement in plasma exposure is due to the improved lymphatic trafficking as evident from the increase in the fraction of dose trafficked through the lymph nodes in the presence of hypertonic buffers. The fraction of the dose trafficked through the lymphatics, as estimated by the model, increased from 0.05% in isotonic buffer to 13% in hypertonic buffer containing NaCl to about 30% for hypertonic buffers containing high dose OPLS and mannitol. The data suggest that hypertonic solutions may be a viable option for improving s.c. bioavailability.

Mannitol versus hypertonic saline for brain relaxation in patients undergoing craniotomy.

BACKGROUND: Patients with brain tumour usually suffer from increased pressure in the skull due to swelling of brain tissue. A swollen brain renders surgical removal of the brain tumour difficult. To ease surgical tumour removal, measures are taken to reduce brain swelling, often referred to as brain relaxation. Brain relaxation can be achieved with intravenous fluids such as mannitol or hypertonic saline. This review was conducted to find out which of the two fluids may have a greater impact on brain relaxation. OBJECTIVES: The objective of this review was to compare the effects of mannitol versus those of hypertonic saline on intraoperative brain relaxation in patients undergoing craniotomy. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 10), MEDLINE via Ovid SP (1966 to October 2013) and EMBASE via Ovid SP (1980 to October 2013). We also searched specific websites, such as www.indmed.nic.in, www.cochrane-sadcct.org and www.Clinicaltrials.gov. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared the use of hypertonic saline versus mannitol for brain relaxation. We also included studies in which any other method used for intraoperative brain relaxation was compared with mannitol or hypertonic saline. Primary outcomes were longest follow-up mortality, Glasgow Outcome Scale score at three months and any adverse events related to mannitol or hypertonic saline. Secondary outcomes were intraoperative brain relaxation, intensive care unit (ICU) stay, hospital stay and quality of life. DATA COLLECTION AND ANALYSIS: We used standardized methods for conducting a systematic review, as described by the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. All analyses were made on an intention-to-treat basis. We used a fixed-effect model when no evidence was found of significant heterogeneity between studies, and a random-effects model when heterogeneity was likely. MAIN RESULTS: We included six RCTs with 527 participants. Only one RCT was judged to be at low risk of bias. The remaining five RCTs were at unclear or high risk of bias. No trial mentioned the primary outcomes of longest follow-up mortality, Glasgow Outcome Scale score at three months or any adverse events related to mannitol or hypertonic saline. Three trials mentioned the secondary outcomes of intraoperative brain relaxation, hospital stay and ICU stay; quality of life was not reported in any of the trials. Brain relaxation was inadequate in 42 of 197 participants in the hypertonic saline group and in 68 of 190 participants in the mannitol group. The risk ratio for brain bulge or tense brain in the hypertonic saline group was 0.60 (95% confidence interval (CI) 0.44 to 0.83, low-quality evidence). One trial reported ICU and hospital stay. The mean (standard deviation (SD)) duration of ICU stay in the mannitol and hypertonic saline groups was 1.28 (0.5) and 1.25 (0.5) days (P value 0.64), respectively; the mean (SD) duration of hospital stay in the mannitol and hypertonic saline groups was 5.7 (0.7) and 5.7 (0.8) days (P value 1.00), respectively AUTHORS' CONCLUSIONS: From the limited data available on the use of mannitol and hypertonic saline for brain relaxation during craniotomy, it is suggested that hypertonic saline significantly reduces the risk of tense brain during craniotomy. A single trial suggests that ICU stay and hospital stay are comparable with the use of mannitol or hypertonic saline. However, focus on other related important issues such as long-term mortality, long-term outcome, adverse events and quality of life is needed.

[Severe allergic reaction due to a rectal enema]. / Réaction allergique sévère suite à un lavement.

Allergic drug reactions must always be considered when prescribing treatment, even in frequent pediatric problems such as acute abdominal pain due to constipation. We describe an original case of anaphylactic shock due to the administration of hypertonic rectal enema in a child. A 9-year-old child admitted to the emergency department for an acute complaint of abdominal pain related to constipation received an administration of a hypertonic rectal enema to allow the passage of stools. Afterwards, the child presented a life-threatening episode, requiring emergency treatment with transfer to the pediatric intensive care unit, suggesting an anaphylactic shock. The absence of any other drug or food intake, the chronology of events, and favorable outcome after treatment led to the diagnosis of a probable allergy to methylparaben, sodium parahydroxybenzoate, present as the excipient in the rectal enema. Anaphylactic shock is a serious allergic reaction, setting in rapidly, which may lead to fatal outcome. Most reactions to parabens reported concern, almost exclusively, the cutaneous application of paraben-containing topical preparations. The present observation underscores the original and undescribed risk of an allergic general reaction following the rectal administration of parabens. The indications of any prescription must be carefully observed and potential drug contraindications, considering the patient's history of allergy, should be sought.

[Preparation for colonoscopy: types of scales and cleaning products]. / Preparación para colonoscopia: tipos de productos y escalas de limpieza.

Adequate bowel preparation is essential before a colonoscopy, allowing us to make a proper examination of the entire mucosa. The ideal method of colon cleansing should be fast, safe, and get a proper cleaning with minimal discomfort for the patient. Today we have a wide variety of colon cleansing products, information sometimes becomes confused. A good colon preparation depends partly on correct choice of the same, but also upon dietary restriction. Knowledge of all these products, with their advantages and limitations, we can make a better selection for each patient, and although the efficacy is comparable, is the experience of the browser, patient preferences, and the degree of compliance with the instructions preparation, which greatly influence the results.

Bolus injection of hypertonic solutions for cerebral edema in rats: challenge of homeostasis of healthy brain.

Hypertonic solutions are mainstay of osmotherapy to cerebral edema. How hypertonic solutions affect healthy brain homeostasis, however, is not fully understood. Using rat model of cerebral edema induced by local cryoinjury, we found with immunohistochemistry that less microglial activation in healthy hemishere 24 h after hypertonic saline (HS, 3% NaCl) administration, compared to mannitol (20%, the same osmotic concentration of 3% NaCl) while dehydrating the brain tissue. To see whether blood-brain barrier (BBB) or aquaporin-4 (AQP4) contribute to this difference, HS or mannitol was intra-arterially injected to normal rats, and BBB opening, ultrastructure and AQP4 immunoreactivity were examined. Evans blue extravasation indicated that BBB was opened much lighter in HS group than mannitol group at the same time points. Electron microscopy also showed edema around the capillaries slightly lighter in HS than mannitol group 24 h after injection. Meanwhile, HS injection led to AQP4 down regulation in expression similarly as mannitol, compared with NS group. These data suggested that bolus injection of hypertonic agents may lead to microglia activation in healthy brain in different extent, due to BBB compromise, instead of water movement or AQP4 expression. Hence in clinical application, BBB of healthy brain should be considered in perspective to maintain the brain homeostasis.

Hydroelectrolytic balance and cerebral relaxation with hypertonic isoncotic saline versus mannitol (20%) during elective neuroanesthesia.

BACKGROUND AND OBJECTIVES: Cerebral relaxation during intracranial surgery is necessary, and hiperosmolar therapy is one of the measures used to this end. Frequently, neurosurgical patients have sodium imbalances. The objective of the present study was to quantify and determine cerebral relaxation and duration of hydroelectrolytic changes secondary to the use of mannitol versus hypertonic isoncotic solution (HIS) during neurosurgery. METHODS: Cerebral relaxation and hydroelectrolytic changes were evaluated in 29 adult patients before de beginning of infusion, and 30 and 120 minutes after the infusion of equiosmolar loads of approximately 20% mannitol (250 mL) or HIS (120 mL). The volume of intravenous fluids infused and diuresis were recorded. A p < 0.05 was considered significant. RESULTS: A statistically significant difference in cerebral relaxation between both groups was not observed. Although several changes in electrolyte levels and acid-base balance with mannitol or HIS reached statistical significance only the reduction in plasma sodium 30 minutes after infusion of mannitol, mean of 6.42 ± 0.40 mEq.L(-1), and the increase in chloride, mean of 5.41 ± 0.96 mEq.L(-1) and 5.45 ± 1.45 mEq.L(-1) 30 and 120 minutes after infusion of HIS, caused a transitory dislocation of serum ion levels from normal range. The mannitol (20%) group had a significantly greater diuresis at both times studied compared with HIS group. CONCLUSIONS: A single dose of hypertonic isoncotic saline solution [7.2% NaCl/6% HES (200/0.5)] and mannitol (20%) with equivalent osmolar loads were effective and safe in producing cerebral relaxation during elective neurosurgical procedures under general anesthesia.

Glutamate release through connexin 43 by cultured astrocytes in a stimulated hypertonicity model.

We investigated the role of connexin 43 (Cx43) hemichannels in the release of glutamate by astrocytes after hypertonic stimulus. Mechanical, osmotic and oxidative stress, and changes in the extracellular or intracellular Ca(2+) levels induce connexin hemichannels located in the plasma membrane to open and release small ions and molecules with signaling potential such as glutamate, ATP, etc. In our past studies, we primarily found that acute hypertonic stimulus induced the release of glutamate. Since glutamate release was involved with several routes, we studied its release routes by astrocytes incubated in a hypertonic media for various periods. The glutamate release was increased after hypertonic stimulus. Glutamate release in hypertonic stimulus was inhibited by gap junction or Cx43 hemichannel blockers, but not by antagonists of purinergic receptor (P2XnR), glutamate transport inhibitors, intracellular Ca(2+) blockers, and pannexin 1(Panx1) hemichannel. The results suggest that glutamate release by the Cx43 hemichannels is likely to feature in the response of cultured astrocytes to hypertonic stimulus.

TRPV1 activation is required for hypertonicity-stimulated inflammatory cytokine release in human corneal epithelial cells.

PURPOSE: To determine whether hypertonic stress promotes increases in inflammatory cytokine release through transient receptor potential vanilloid channel type 1 (TRPV1) signaling pathway activation in human corneal epithelial cells (HCECs). METHODS: Hyperosmotic medium was prepared by supplementing isotonic Ringers solution with sucrose. Ca2+ signaling was measured in fura2-AM-loaded HCECs using a single-cell fluorescence imaging system. Western blot analysis evaluated the phosphorylation status of EGFR, ERK, p38 MAPK, and nuclear factor (NF)-κB. ELISA assessed the effect of TRPV1 activation on the release of IL-6 and IL-8. RESULTS: A 450 mOsm hypertonic stress elicited 2-fold Ca2+ transients that were suppressed by the TRPV1-selective antagonists capsazepine and JYL 1421. Such transients were enhanced by PGE2. Hypertonicity-induced EGF receptor (EGFR) transactivation was suppressed by preincubating HCECs with capsazepine, matrix metalloproteinase 1 (MMP1) inhibitor TIMP-1, broad-spectrum MMP inhibitor GM 6001, heparin-bound (HB)-EGF inhibitor CRM 197, or EGFR inhibitor AG 1478. ERK and p38 MAPK and NF-κB activation after EGFR transactivation occurred in tonicity and in a time-dependent manner. Hypertonicity-induced increases in IL-6 and IL-8 releases were suppressed by exposure to capsazepine, AG 1478, ERK inhibitor PD 98059, p38 inhibitor SB 203580, or NF-κB inhibitor PDTC. CONCLUSIONS: Hypertonic stress-elicited TRPV1 channel stimulation mediates increases in a proinflammatory cytokine IL-6 and a chemoattractant IL-8 by eliciting EGFR transactivation, MAPK, and NF-κB activation. Selective drug modulation of either TRPV1 activity or its signaling mediators may yield a novel approach to suppressing inflammatory responses occurring in dry eye syndrome.

Flow-through peritoneal dialysis in neonatal enema-induced hyperphosphatemia.

Fleet enemas are hypertonic solutions with an osmotic action and a high concentration of phosphate. When retained in the human body they have a great toxic potential, causing severe hydro-electrolyte disorders in children, especially in newborns. We report the case of a previously healthy 8-day-old newborn who needed neonatal intensive care treatment after the inadvertent administration of an osmotically active hypertonic phosphate enema. Taking into account that phosphate removal by peritoneal dialysis (PD) strongly depends on total dialysate turnover, we chose continuous flow PD (CFPD) as the treatment option, with a successful outcome. Clinical experience with this dialytic modality is limited to a few case reports in pediatric and adult patients. To the best of our knowledge, we report here the first description of CFPD in the setting of acute phosphate nephropathy in the neonatal period. The modality of PD described here has potential as an alternative management option as it is a highly efficient, methodologically simple, and low-cost method without any need for sophisticated equipment. Physicians and parents should be aware of the adverse effects of a hypertonic phosphate enema and should never use these medications in infants and newborns.

Influences of hypertonic and hypovolemic treatments on vasopressin response in propylthiouracil (PTU) induced hypothyroid rat and effect on supplementation with L-thyroxine.

This study was performed to investigate the effects of L-thyroxine treatment on plasma vasopressin (AVP) levels in rats with hypothyroidism induced by propylthiouracil (PTU). Animals were separated into three groups each having 6 rats: control, PTU, PTU+L-thyroxine groups. Then, the groups were further divided into 3 sub-groups including 6 rats (a; basal, b; hypertonic stimulated and c; hypovolemic stimulated). At the end of the experiments all rats were decapitated in order to obtain plasma samples for analysis in terms of Hct, osmolality, TT 3 , TT 4 and vasopressin. Haematocrit (Hct) levels were the highest in hypovolemic stimulated sub-group (P < 0.001). Osmolality levels were higher in hypertonic stimulated sub-groups (P < 0.001). Total T 3 and T 4 values were the lowest in the PTU group and the highest in the L-thyroxine treated group (P < 0.001). Plasma AVP levels were reduced by hypothyroidism. However, L-thyroxine treatment after the hypothyroidism prevented this reduction (P < 0.001). Vasopressin responses to basal, hypovolemic and hypertonic stimulations were the lowest in the PTU group (P < 0.001). The results of the present study show that basal and stimulated plasma vasopressin levels are reduced in PTU-induced hypothyroidism. However, L-thyroxine treatment following hypothyroidism prevents this reduction.

Cura de orificio de salida de catéter: ciprofloxacino versus suero hipertónico 20 % / No disponible

No disponible

Effect of semen dilution to low-sperm number per dose on motility and functionality of cryopreserved bovine spermatozoa using low-density lipoproteins (LDL) extender: comparison to Triladyl and Bioxcell.

Artificial insemination with doses containing low-sperm numbers has been utilized to optimize the use of elite bulls. Hen egg yolk is widely used as a cryoprotective agent in semen freezing extender protecting the spermatozoa. Its action is due to the presence of low-density lipoproteins (LDL) in the hen egg yolk. The objectives of the present study were to evaluate the effects of the semen dilution to low-sperm number/dose on sperm motility and integrity of sperm plasma membrane in the cryopreservation process, using two commercial extenders (Triladyl, Bioxcell and LDL extender prepared in our laboratory, 97% purity. Fifteen ejaculates were collected from five fertile crossbred bulls (Bos taurusxBos indicus). After collection, sperm motility was examined by Computer-Assisted Semen Analysis (Hamilton Thorne), morphological sperm characteristics were evaluated by differential interference microscopy and the integrity of plasma membranes was determined using the hypo-osmotic swelling test. The semen was subsequently divided into three aliquots and diluted with the three extenders into 120 x 10(6), 60 x 10(6) and 20 x 10(6)sperm/mL, corresponding to 30 x 10(6), 15 x 10(6) and 5 x10(6) sperm/dose, respectively. This study revealed that LDL extender was more effective in preservation of motility and integrity of the plasma membrane of spermatozoa than Bioxcell and Triladyl (p<0.05), but no significant difference was observed between Triladyland Bioxcell. Therefore we can conclude that LDL extender could be used instead of Triladyl or Bioxcellat low semen concentration per dose for elite bulls, it also could be envisaged for the industry of sex-stored semen.

Enema-induced severe hyperphosphatemia in children.

We report the case of a 13-year-old boy with Costello syndrome and chronic constipation who received phosphate-containing Fleet-pediatric enemas at regular intervals. The day before admission he was given four enemas for severe constipation. Within 24 h the boy had developed severe hyperphosphatemia (phosphate 17.75 mmol/L), hypertonic dehydration (sodium 171 mmol/L) and severe hypocalcemia (calcium 0.56 mmol/L). With early intervention and treatment, the child survived without sequelae. Osmotically acting hypertonic phosphate enemas may result in severe toxicity. Children with developmental delay often display bowel dysfunction and chronic constipation and are therefore high-risk patients. The accepted opinion-that these enemas are not absorbed and therefore systemically inactive-is not true. Physicians should be aware of the potentially lethal complications of this treatment, which is part of everyday clinical practice.